ICU without walls

concept;
Early detection and intervention of
patients at risk of cardiac arrest
outside the ICU

Etiology of cardiac arrest

Etiologi
Cardiac (primary) OHCA
Heart attack (MCI)
Kelainan jantung lain

Non-Cardiac (secondary) IHCA

Internal
Severe Pneumonia, Septic Shock, etc

External
Trauma hemorrhage, Intoxication etc

Nolan J. ERC Guidelines for Resuscitation 2005-introduction. Resuscitation. 2005; 67

(suppl1):S3-S6

Etiology of OHCA
(Out-of-hospital Cardiac Arrest)

Nolan J. ERC Guidelines for

Resuscitation 2005introduction.
Resuscitation. 2005; 67
(suppl 1):S3-S6

Definition
The Utstein-style definition of cardiac arrest
(2004);
the cessation of cardiac mechanical activity. . .
confirmed by the absence of a detectable pulse,
unresponsiveness and apnoea (or agonal respirations)

This definition distinguishes cardiac arrest from

respiratory arrest, which is characterised by
apnoea with palpable pulses.
According to the Utstein criteria, a cardiac arrest
is classified as in-hospital if it occurs in a
hospitalised patient who had a pulse at the time
Jacobs
I, Nadkarni
V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coova- dia A, DEste K, Finn J, Halperin H, Handley A,
of
admission.
Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL, Mancini ME, Mason P, Mears G, Monsieurs K, Montgomery W, Morley P,
Nichol G, Nolan J, Okada K, Perlman J, Shus- ter M, Steen PA, Sterz F, Tibballs J, Timerman S, Truitt T, Zideman D (2004)
Cardiac arrest and cardiopul- monary resuscitation outcome reports: update and simplification of the Utstein templates for
resuscitation registries. Resuscitation 63:233249

In-Hospital Cardiac Arrest

In US, between 370,000 and 750,000 in-hospital
resuscitation attempts are made each year.
Intensivists are frequently involved in the
management of in-hospital cardiac arrests (IHCAs)
as members of cardiac arrest teams
or to provide post-resuscitation care.

Problem;
majority of patients resuscitated successfully from IHCA die
before hospital discharge, and their prognosis has changed little
over the past 30 years

Ballew KA, Philbrick JT (1995) Causes of variation in reported in-hospital CPR survival: a critical review. Resuscitation
30:203215
Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, Berg RA, Nichol G, Lane-Trultt T (2003)
Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of

In-Hospital Cardiac Arrest

Delays in the treatment of hospitalized patients often result
in emergency admission to the ICU, which in turn implies a
prolongation of hospital stay and even increased mortality.
(Goldhill DR. Medical emergency teams. Care Crit Ill. 2000)

50% of hospitalized patients failed to receive optimum

management before admission to the ICU, and that 40% of
all admissions to the ICU are in fact avoidable. (McQuillan BMJ
1998)

On the other hand, delays in admission to the ICU - mainly

due to a limitation or shortage of available beds
Mortality increase in the ICU and in hospital 1.5% and 1% respectively,
for every hour of delayed admission. (Cardoso et al. Crit Care 2011)

Incidence
Incidence of 0.175 events/bed
annually over a total of 14,720
arrests in 287 American hospi- tals
(Peberdy et 2003)

Incidence of 1 to 5 arrests per 1000

patient admissions (Skogvoll et al,1999),
(Hodgetts et al 2002), (Sandroni 2004)

Survival
Survival from cardiac arrest can be expressed in relation to time
as:
immediate (ROSC),
short-term (discharged alive from the hospital), and
long-term (612 months).

ROSC represents mainly a success of the cardiopulmonary

resuscitation (CPR) manoeuvres. Unfortunately, between 25%
and 67% of the successfully resuscitated patients die during the
first 24 h after ROSC (Sandroni 2004), (Tunstall-Pedoe 1992) (Skrifvars
2003)

Survival to hospital discharge is the most commonly quoted

outcome. documented survival rates for IHCA range from 0% to
42%, although major studies report a survival to discharge of
approx. 20%

Survival rate of OHCA and

IHCA

The American Heart Association published the Heart Disease and

Stroke Statistics - 2013 Update online on December 12, 2012.

How to improve the outcome?

1. Pre-arrest factors:
Recognising the critically ill patient and
prevention of cardiac arrest.
Up to 84% cases have evidence of deterioration during
the 8 hours before the arrest
the most common findings being respiratory problems,
deterioration of mental status and haemodynamic instability.
Kause J et al (2004), Franklin C et al (1994) Schein RM et al (1990)

61.9% of arrests were potentially avoidable. Clinical signs

of deterioration were not acted on in 48% of cases.
The odds of potentially avoidable cardiac arrests were 5.1
times higher in patients in general wards than in critical
care areas. Hodgetts et al (2004)

Results
Results:

Among patients with preexisting pneumonia, only 36.5%

were receiving mechanical ventilation and only 33.3%
were receiving infusions of vasoactive drugs prior to
cardiac arrest.
Only 52.3% of patients on the ward were receiving ECG
monitoring prior to cardiac arrest.
Shockable rhythms were uncommon in all patients with
pneumonia (ventricular tachycardia or fibrillation,
14.8%).
Patients on the ward were significantly older than
patients in the ICU.

Conclusions:

In patients with preexisting pneumonia, cardiac arrest

may occur in the absence of preceding shock or
respiratory failure. Physicians should be alert to the
possibility of abrupt cardiopulmonary collapse
The mechanism may involve myocardial ischemia, a
maladaptive response to hypoxia, sepsis-related

How to improve the outcome?

1. Pre-arrest factors:
Medical Emergency Teams
Early detection of patients at risk

Cardiac Arrest outside the ICU after

RRT

Implementation of an RRT in adults was associated with a

33.8% reduction in rates of cardiopulmonary arrest outside
the intensive care unit (ICU)

Hospital mortality after RRT

Implementation of an RRT in adults was not

associated with lower hospital mortality rates

Conclusion of this metaanalysis

Possibilities for these counterintuitive results are
early identification and transfer of the patient to the
ICU, where the patient subsequently experiences an
IHCA, and
increased use of DNAR orders.
Other possibilities include failure to trigger the team
when signs of deterioration are noted and poor
surveillance methods for identifying clinical
deterioration

How to improve the outcome?

2. Intra-arrest factors:
Resuscitation Guidelines 2010

How to improve the outcome?

3. Post-resuscitation care:
The prognosis of patients admitted to the ICU after
resuscitation from cardiac arrest is poor in comparison
with other ICU patients
Among 14,258 patients admitted to ICU in the United
Kingdom after IHCA the ICU mortality was 55% while
hospital mortality was 69%
Interventions in the post-resuscitation period are likely
to influence the final outcome significantly
Guidelines of resuscitation 2010

How to improve the outcome?

Best Practices
The best practices are divided into 3 temporal
sections
Pre-arrest, intra-arrest, and post-arrest.
The discussion for each period includes;
(1) a brief introduction,
(2) the structural aspects of the institutional response
(personnel, training, equipment),
(3) care pathways followed during the time interval
early identification,
focus on CPR and early defibrillation,
comprehensive post-arrest care, and

(4) process issues related to how care is provided and quality

improvement measures
(real-time feed- back, automated equipment that can replace staff and
deliver similar care, withdrawal of life-sustaining therapy).

Conclusion
Outcome from IHCA is determined by pre, intra- and post-arrest
factors.
Some pre-arrest conditions are time-dependent disease such as
cancer, sepsis and renal failure are correlated with lower survival
Many in-hospital arrests are preceded by warning signs, which
should be identified early to enable treatment to prevent patient
deterioration.
Experience with specifically dedicated teams increased
awareness of warning signs by ward personnel
After cardiac arrest has occurred, better resuscitation, early
defibrillation and induced-hypothermia can improve survival.
Recent evidence that better CPR is associated with increased
resuscitation success should be translated into systematic
training and maintenance of skills among all healthcare providers.

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